Quote from c tran
i have a care plan that i am stuck on. i got a patient who was admitted for sob, renal insufficiency, altered mental status and was dx with renal insufficiency, sob, copd, and urosepsis. he has a hx of hypertension, cancer, bph,and chf. no where in the the patient history does he have cholesterol problem so why is he given lipitor? also his lab h+h is low, rdw is high but mcv, mch, and mchc are normal? no report of him being anemic so why is his rdw is high which indicates anisocytosis? doesn't anisocytosis indicate b12 vitamin anemia? i am so confused, any help is appreciated. thanks.
make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment? is the patient having pain? are they having difficulty with adls? what teaching do they need? most renal patients are on fluid restrictions. what does the patient say? what are the labs? is the patient on dialysis? is the patient compliant with the dialysis? what does the patient need? what is the most important to them now?
the medical diagnosis is the disease itself. it is what the patient has
not necessarily what the patient needs.
the nursing diagnosis is what are you
going to do
about it, what are you going to look
for, and what do you need to do/look for first.
care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.
from a very wise an contributor daytonite.......
every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care
plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans
. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help
you in writing care plans
so you diagnose your patients correctly.
don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics
. a dear an contributor daytonite always had the best advice.......check out this link.
what do you know about renal failure? can renal failure cause chronic anemia? what is your patient complaining of? sob? confusion? what do you know of htn? can clogged arterires cause htn and maybe needs rx with lipitor? is his safety in danger with the confusion? does he have ineffective breathing pattern? does he have an activity intolerance? is he at risk for falls? does he have excess fluid volume causing his sob? impaired gas exchange due to excess fluid volume or copd? can he care for himself? is he at risk for skin tears from falls?
this is for starts......what are your thoughts?
these sites may help
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
nursing care plans, care maps and nursing diagnosis